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M. Alexander Otto began his reporting career early in 1999 covering the pharmaceutical industry for a national pharmacists' magazine and freelancing for the Washington Post and other newspapers. He then joined BNA, now part of Bloomberg News, covering health law and the protection of people and animals in medical research. Alex next worked for the McClatchy Company. Based on his work, Alex won a year-long Knight Science Journalism Fellowship to MIT in 2008-2009. He joined the company shortly thereafter. Alex has a newspaper journalism degree from Syracuse (N.Y.) University and a master's degree in medical science -- a physician assistant degree -- from George Washington University. Alex is based in Seattle.
Keep warning teens of tanning bed risks
Although efforts to keep minors out of tanning salons are gaining momentum, there’s still a need for dermatologists, pediatricians, and others to advocate for legislation and educate patients – especially teens and their parents – about melanoma and other tanning risks, according to a review of the issue in the December 2013 issue of Seminars in Cutaneous Medicine and Surgery.
"Even though many medical professionals, patients, and legislators agree with and support the passage of legislation to ban or limit tanning in minors and/or the general population, it is often difficult for laws to be successfully enacted" because of ignorance of the risks, tanning industry opposition, and "social norms ... which regard tanned skin as more attractive," wrote Dr. Teresa Foo, a preventive medicine resident at the Colorado School of Public Health in Aurora, and Dr. Robert Dellavalle, chief of the dermatology service at the Veterans Affairs Medical Center in Denver.
However, the researchers expressed hope that, as with tobacco use, "legislation limiting indoor tanning will help to change social norms and reduce usage" (Sem. Cut. Med. Surg. 2013;32:217-23).
In recent years, 35 states have enacted measures to curb child and teen access to tanning beds, with efforts ranging from outright bans for those younger than 17 or 18 years to parent consent requirements, written customer warnings, advertising restrictions, and limits on exposure time. Still, enforcement can be spotty, laws are inconsistent from one state to the next, and some states have no laws related to indoor tanning and minors.
The federal government has worked on the issue, as well. The Food and Drug Administration is considering reclassifying sunlamps as moderate risk, instead of low risk, and the Federal Trade Commission has placed restrictions on tanning promotional materials. The Affordable Care Act also put a 10% excise tax on indoor tanning, which is being passed on to consumers and causing some to shy away. A federal ban, however, seems a long way off.
"In the United States, the lack of coordination of statewide efforts and the lack of a strong national statement regarding the harms of indoor tanning may be slowing the success of legislation to ban tanning for minors," the authors noted. There remains a "need for strong legislation with the inclusion of specific enforcement policies and penalties. ... The more strict the legislation, the less chance of misinterpretation or improper compliance by tanning facilities," they said.
"Dermatologists and other health care providers need to become patient advocates and discuss the harms of indoor tanning with patients, especially teens and their parents. It is essential for dermatologists and the medical profession as a whole to continue to educate legislators and the public regarding the harms of indoor tanning and the need for legislation to protect not just our teenagers, but also the general population," the investigators emphasized.
Realistic goals, building relationships with local medical organizations, and finding bipartisan bill sponsors will likely aid legislative efforts. Melanoma advocacy groups, school-based teacher and parent groups, and state and national organizations will likely lend a hand, as well, they added.
This work was supported in part by grant number D33HP02610 to the University of Colorado Preventive Medicine Residency Program from the Health Resources and Services Administration (HRSA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA.
Although efforts to keep minors out of tanning salons are gaining momentum, there’s still a need for dermatologists, pediatricians, and others to advocate for legislation and educate patients – especially teens and their parents – about melanoma and other tanning risks, according to a review of the issue in the December 2013 issue of Seminars in Cutaneous Medicine and Surgery.
"Even though many medical professionals, patients, and legislators agree with and support the passage of legislation to ban or limit tanning in minors and/or the general population, it is often difficult for laws to be successfully enacted" because of ignorance of the risks, tanning industry opposition, and "social norms ... which regard tanned skin as more attractive," wrote Dr. Teresa Foo, a preventive medicine resident at the Colorado School of Public Health in Aurora, and Dr. Robert Dellavalle, chief of the dermatology service at the Veterans Affairs Medical Center in Denver.
However, the researchers expressed hope that, as with tobacco use, "legislation limiting indoor tanning will help to change social norms and reduce usage" (Sem. Cut. Med. Surg. 2013;32:217-23).
In recent years, 35 states have enacted measures to curb child and teen access to tanning beds, with efforts ranging from outright bans for those younger than 17 or 18 years to parent consent requirements, written customer warnings, advertising restrictions, and limits on exposure time. Still, enforcement can be spotty, laws are inconsistent from one state to the next, and some states have no laws related to indoor tanning and minors.
The federal government has worked on the issue, as well. The Food and Drug Administration is considering reclassifying sunlamps as moderate risk, instead of low risk, and the Federal Trade Commission has placed restrictions on tanning promotional materials. The Affordable Care Act also put a 10% excise tax on indoor tanning, which is being passed on to consumers and causing some to shy away. A federal ban, however, seems a long way off.
"In the United States, the lack of coordination of statewide efforts and the lack of a strong national statement regarding the harms of indoor tanning may be slowing the success of legislation to ban tanning for minors," the authors noted. There remains a "need for strong legislation with the inclusion of specific enforcement policies and penalties. ... The more strict the legislation, the less chance of misinterpretation or improper compliance by tanning facilities," they said.
"Dermatologists and other health care providers need to become patient advocates and discuss the harms of indoor tanning with patients, especially teens and their parents. It is essential for dermatologists and the medical profession as a whole to continue to educate legislators and the public regarding the harms of indoor tanning and the need for legislation to protect not just our teenagers, but also the general population," the investigators emphasized.
Realistic goals, building relationships with local medical organizations, and finding bipartisan bill sponsors will likely aid legislative efforts. Melanoma advocacy groups, school-based teacher and parent groups, and state and national organizations will likely lend a hand, as well, they added.
This work was supported in part by grant number D33HP02610 to the University of Colorado Preventive Medicine Residency Program from the Health Resources and Services Administration (HRSA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA.
Although efforts to keep minors out of tanning salons are gaining momentum, there’s still a need for dermatologists, pediatricians, and others to advocate for legislation and educate patients – especially teens and their parents – about melanoma and other tanning risks, according to a review of the issue in the December 2013 issue of Seminars in Cutaneous Medicine and Surgery.
"Even though many medical professionals, patients, and legislators agree with and support the passage of legislation to ban or limit tanning in minors and/or the general population, it is often difficult for laws to be successfully enacted" because of ignorance of the risks, tanning industry opposition, and "social norms ... which regard tanned skin as more attractive," wrote Dr. Teresa Foo, a preventive medicine resident at the Colorado School of Public Health in Aurora, and Dr. Robert Dellavalle, chief of the dermatology service at the Veterans Affairs Medical Center in Denver.
However, the researchers expressed hope that, as with tobacco use, "legislation limiting indoor tanning will help to change social norms and reduce usage" (Sem. Cut. Med. Surg. 2013;32:217-23).
In recent years, 35 states have enacted measures to curb child and teen access to tanning beds, with efforts ranging from outright bans for those younger than 17 or 18 years to parent consent requirements, written customer warnings, advertising restrictions, and limits on exposure time. Still, enforcement can be spotty, laws are inconsistent from one state to the next, and some states have no laws related to indoor tanning and minors.
The federal government has worked on the issue, as well. The Food and Drug Administration is considering reclassifying sunlamps as moderate risk, instead of low risk, and the Federal Trade Commission has placed restrictions on tanning promotional materials. The Affordable Care Act also put a 10% excise tax on indoor tanning, which is being passed on to consumers and causing some to shy away. A federal ban, however, seems a long way off.
"In the United States, the lack of coordination of statewide efforts and the lack of a strong national statement regarding the harms of indoor tanning may be slowing the success of legislation to ban tanning for minors," the authors noted. There remains a "need for strong legislation with the inclusion of specific enforcement policies and penalties. ... The more strict the legislation, the less chance of misinterpretation or improper compliance by tanning facilities," they said.
"Dermatologists and other health care providers need to become patient advocates and discuss the harms of indoor tanning with patients, especially teens and their parents. It is essential for dermatologists and the medical profession as a whole to continue to educate legislators and the public regarding the harms of indoor tanning and the need for legislation to protect not just our teenagers, but also the general population," the investigators emphasized.
Realistic goals, building relationships with local medical organizations, and finding bipartisan bill sponsors will likely aid legislative efforts. Melanoma advocacy groups, school-based teacher and parent groups, and state and national organizations will likely lend a hand, as well, they added.
This work was supported in part by grant number D33HP02610 to the University of Colorado Preventive Medicine Residency Program from the Health Resources and Services Administration (HRSA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA.
FROM SEMINARS IN CUTANEOUS MEDICINE AND SURGERY
Temperature alone doesn’t rule out flu in the ED
SEATTLE – Lowering the Centers for Disease Control and Prevention’s temperature requirement for influenza-like illness from 100º F to 99º F would likely pick up more cases of true influenza in the emergency department, according to researchers at Rush University Medical Center in Chicago.
At Rush, 203 emergency department (ED) patients tested positive for the virus by polymerase chain reaction (PCR) during the 2012-2013 flu season, but only 135 (67%) were identified as having flu-like illness by the ED’s automated surveillance system, which pulls together provider notes, vital signs, and other information from the electronic records system in real time to identify patients with influenza-like illness (ILI), among other conditions.
On chart review, 29 (43%) of the 68 missed cases met the CDC’s requirements for ILI diagnosis: a temperature of at least 100º F, plus cough and/or sore throat. Most likely, the surveillance system was confused by double-negatives in provider notes or similar problems; Rush investigators are looking into the problem.
However, 39 patients with PCR-confirmed influenza did not meet the CDC’s criteria in the ED; in 15 patients (40%) it was because they had a temperature at or above 99º F, but below the 100º F benchmark.
"If you relabeled the fever criteria to greater than or equal to 99 degrees, you would actually pick up more patients. Your sensitivity would be greater, but we don’t know what would happen to the specificity. We haven’t reprogrammed the surveillance system yet to try it," Dr. Marilyn Hallock, an attending physician in the Rush ED, said a the annual meeting of the American College of Emergency Physicians. It’s something "we might want to explore further," she noted.
In the meantime, "I’m going to think twice before I say patients who come in with that gray-zone temperature between of 99º F and 100 º F don’t have influenza; they might," she said.
The rest of the 39 patients were missed for various reasons. A few arrived in respiratory distress or another condition that precluded an accurate history, while others may not have recalled ILI symptoms or were not asked about them. A number of patients were diagnosed on hospital admission from the ED when more thorough histories were taken, or when they developed the CDC triad after admission.
Dr. Hallock suspects viral PCRs were ordered in the ED for the 39 patients – although they didn’t meet CDC criteria – because it was flu season, and they complained of other flu symptoms such as myalgia and aches. "It was probably just a constellation of symptoms that led physicians to give the test," even though the patients’ ED temperatures were below 100 º F, she said.
In addition to perhaps lowering the ILI requirement to 99 º F, the investigators plan to review ILI symptoms with ED staff and work to improve their documentation, said Dr. Hallock, who indicated that she had no relevant disclosures.
SEATTLE – Lowering the Centers for Disease Control and Prevention’s temperature requirement for influenza-like illness from 100º F to 99º F would likely pick up more cases of true influenza in the emergency department, according to researchers at Rush University Medical Center in Chicago.
At Rush, 203 emergency department (ED) patients tested positive for the virus by polymerase chain reaction (PCR) during the 2012-2013 flu season, but only 135 (67%) were identified as having flu-like illness by the ED’s automated surveillance system, which pulls together provider notes, vital signs, and other information from the electronic records system in real time to identify patients with influenza-like illness (ILI), among other conditions.
On chart review, 29 (43%) of the 68 missed cases met the CDC’s requirements for ILI diagnosis: a temperature of at least 100º F, plus cough and/or sore throat. Most likely, the surveillance system was confused by double-negatives in provider notes or similar problems; Rush investigators are looking into the problem.
However, 39 patients with PCR-confirmed influenza did not meet the CDC’s criteria in the ED; in 15 patients (40%) it was because they had a temperature at or above 99º F, but below the 100º F benchmark.
"If you relabeled the fever criteria to greater than or equal to 99 degrees, you would actually pick up more patients. Your sensitivity would be greater, but we don’t know what would happen to the specificity. We haven’t reprogrammed the surveillance system yet to try it," Dr. Marilyn Hallock, an attending physician in the Rush ED, said a the annual meeting of the American College of Emergency Physicians. It’s something "we might want to explore further," she noted.
In the meantime, "I’m going to think twice before I say patients who come in with that gray-zone temperature between of 99º F and 100 º F don’t have influenza; they might," she said.
The rest of the 39 patients were missed for various reasons. A few arrived in respiratory distress or another condition that precluded an accurate history, while others may not have recalled ILI symptoms or were not asked about them. A number of patients were diagnosed on hospital admission from the ED when more thorough histories were taken, or when they developed the CDC triad after admission.
Dr. Hallock suspects viral PCRs were ordered in the ED for the 39 patients – although they didn’t meet CDC criteria – because it was flu season, and they complained of other flu symptoms such as myalgia and aches. "It was probably just a constellation of symptoms that led physicians to give the test," even though the patients’ ED temperatures were below 100 º F, she said.
In addition to perhaps lowering the ILI requirement to 99 º F, the investigators plan to review ILI symptoms with ED staff and work to improve their documentation, said Dr. Hallock, who indicated that she had no relevant disclosures.
SEATTLE – Lowering the Centers for Disease Control and Prevention’s temperature requirement for influenza-like illness from 100º F to 99º F would likely pick up more cases of true influenza in the emergency department, according to researchers at Rush University Medical Center in Chicago.
At Rush, 203 emergency department (ED) patients tested positive for the virus by polymerase chain reaction (PCR) during the 2012-2013 flu season, but only 135 (67%) were identified as having flu-like illness by the ED’s automated surveillance system, which pulls together provider notes, vital signs, and other information from the electronic records system in real time to identify patients with influenza-like illness (ILI), among other conditions.
On chart review, 29 (43%) of the 68 missed cases met the CDC’s requirements for ILI diagnosis: a temperature of at least 100º F, plus cough and/or sore throat. Most likely, the surveillance system was confused by double-negatives in provider notes or similar problems; Rush investigators are looking into the problem.
However, 39 patients with PCR-confirmed influenza did not meet the CDC’s criteria in the ED; in 15 patients (40%) it was because they had a temperature at or above 99º F, but below the 100º F benchmark.
"If you relabeled the fever criteria to greater than or equal to 99 degrees, you would actually pick up more patients. Your sensitivity would be greater, but we don’t know what would happen to the specificity. We haven’t reprogrammed the surveillance system yet to try it," Dr. Marilyn Hallock, an attending physician in the Rush ED, said a the annual meeting of the American College of Emergency Physicians. It’s something "we might want to explore further," she noted.
In the meantime, "I’m going to think twice before I say patients who come in with that gray-zone temperature between of 99º F and 100 º F don’t have influenza; they might," she said.
The rest of the 39 patients were missed for various reasons. A few arrived in respiratory distress or another condition that precluded an accurate history, while others may not have recalled ILI symptoms or were not asked about them. A number of patients were diagnosed on hospital admission from the ED when more thorough histories were taken, or when they developed the CDC triad after admission.
Dr. Hallock suspects viral PCRs were ordered in the ED for the 39 patients – although they didn’t meet CDC criteria – because it was flu season, and they complained of other flu symptoms such as myalgia and aches. "It was probably just a constellation of symptoms that led physicians to give the test," even though the patients’ ED temperatures were below 100 º F, she said.
In addition to perhaps lowering the ILI requirement to 99 º F, the investigators plan to review ILI symptoms with ED staff and work to improve their documentation, said Dr. Hallock, who indicated that she had no relevant disclosures.
AT THE ACEP SCIENTIFIC ASSEMBLY 2013
Major finding: Thirty-nine of 203 PCR-confirmed influenza patients did not meet CDC influenza-like illness criteria in the ED. Most often, their temperature was below 100º F.
Data Source: Retrospective cross-sectional study.
Disclosures: The presenter has no relevant disclosures.
Women’s Sexuality Diminished by Psoriasis
LAS VEGAS – Psoriasis has a negative impact on women’s sexual desire, sexual ability, and sexual relationships, according to Dr. Jennifer Cather of the Modern Dermatology-Aesthetics Center in Dallas.
Dr. Cather and her colleagues are developing a clinical tool to assess the disease’s sexual impact; as part of those efforts, they conducted 60 interviews with moderately to severely psoriatic women with a mean age of 41 years.
The survey results showed that sexuality was clearly another reason why it’s important to keep psoriasis in check. Pain and itchiness during sex, self-consciousness and embarrassment, and avoidance of dating and intimate relationships were among the most common problems the women reported.
"We really didn’t appreciate the impact psoriasis had on relationships" before the survey, Dr. Cather said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar. "The sexual impact has been underappreciated," she said.
Those problems might help explain why women with psoriasis, especially those aged younger than 35 years, tend to have fewer babies, she added. Psoriatic women also have higher rates of induced and spontaneous abortions and are more likely to have preterm and underweight births.
Some of the women surveyed said that they worried about passing psoriasis to their children. "Maybe there’s voluntary childlessness," Dr. Cather said. But when women in her practice mention they don’t want kids for fear of passing on the disease, "I answer right back, ‘You don’t have to have what you have. I can help you with it,’ " she said.
Methotrexate, acitretin, and psoralen photochemotherapy (PUVA) are contraindicated during pregnancy, but ultraviolet B (UVB) treatments are safe, said Dr. Cather. She also uses tumor necrosis factor inhibitors, which are FDA pregnancy category B agents; she prefers etanercept for its short half-life (just over 4 days) and because ob.gyns. are usually familiar with it. The Organization of Teratology Information Specialists (OTIS) keeps the etanercept and adalimumab pregnancy registries, and "there’s [been] no signal to date" for those drugs, she said.
Psoriatic women should know that the odds are with them for having a normal pregnancy, and that pregnancy is likely to help clear their skin, Dr. Cather said.
But because half of the pregnancies in the United States are unplanned, it’s important to discuss pregnancy – and psoriasis treatment during pregnancy – as part of routine care. "It’s difficult if a psoriasis patient calls you in a panic because they’re not sure their drug is safe, and not sure their doctor will let them continue it,’ she said. Some ob.gyns. are comfortable with letting women stay on their psoriasis therapy, while others want them to quit everything, even topical steroids.
"In my clinic, when a psoriasis patient gets pregnant, usually we’ve planned for it and are excited about it, and we’ve had some dialogue with the ob.gyn.," she explained.
SDEF and this news organization are owned by Frontline Medical Communications. Dr. Cather is a consultant, speaker, or researcher for AbbVie, Novartis, Leo, Janssen, Amgen, Celgene, Merck, and Pfizer.
LAS VEGAS – Psoriasis has a negative impact on women’s sexual desire, sexual ability, and sexual relationships, according to Dr. Jennifer Cather of the Modern Dermatology-Aesthetics Center in Dallas.
Dr. Cather and her colleagues are developing a clinical tool to assess the disease’s sexual impact; as part of those efforts, they conducted 60 interviews with moderately to severely psoriatic women with a mean age of 41 years.
The survey results showed that sexuality was clearly another reason why it’s important to keep psoriasis in check. Pain and itchiness during sex, self-consciousness and embarrassment, and avoidance of dating and intimate relationships were among the most common problems the women reported.
"We really didn’t appreciate the impact psoriasis had on relationships" before the survey, Dr. Cather said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar. "The sexual impact has been underappreciated," she said.
Those problems might help explain why women with psoriasis, especially those aged younger than 35 years, tend to have fewer babies, she added. Psoriatic women also have higher rates of induced and spontaneous abortions and are more likely to have preterm and underweight births.
Some of the women surveyed said that they worried about passing psoriasis to their children. "Maybe there’s voluntary childlessness," Dr. Cather said. But when women in her practice mention they don’t want kids for fear of passing on the disease, "I answer right back, ‘You don’t have to have what you have. I can help you with it,’ " she said.
Methotrexate, acitretin, and psoralen photochemotherapy (PUVA) are contraindicated during pregnancy, but ultraviolet B (UVB) treatments are safe, said Dr. Cather. She also uses tumor necrosis factor inhibitors, which are FDA pregnancy category B agents; she prefers etanercept for its short half-life (just over 4 days) and because ob.gyns. are usually familiar with it. The Organization of Teratology Information Specialists (OTIS) keeps the etanercept and adalimumab pregnancy registries, and "there’s [been] no signal to date" for those drugs, she said.
Psoriatic women should know that the odds are with them for having a normal pregnancy, and that pregnancy is likely to help clear their skin, Dr. Cather said.
But because half of the pregnancies in the United States are unplanned, it’s important to discuss pregnancy – and psoriasis treatment during pregnancy – as part of routine care. "It’s difficult if a psoriasis patient calls you in a panic because they’re not sure their drug is safe, and not sure their doctor will let them continue it,’ she said. Some ob.gyns. are comfortable with letting women stay on their psoriasis therapy, while others want them to quit everything, even topical steroids.
"In my clinic, when a psoriasis patient gets pregnant, usually we’ve planned for it and are excited about it, and we’ve had some dialogue with the ob.gyn.," she explained.
SDEF and this news organization are owned by Frontline Medical Communications. Dr. Cather is a consultant, speaker, or researcher for AbbVie, Novartis, Leo, Janssen, Amgen, Celgene, Merck, and Pfizer.
LAS VEGAS – Psoriasis has a negative impact on women’s sexual desire, sexual ability, and sexual relationships, according to Dr. Jennifer Cather of the Modern Dermatology-Aesthetics Center in Dallas.
Dr. Cather and her colleagues are developing a clinical tool to assess the disease’s sexual impact; as part of those efforts, they conducted 60 interviews with moderately to severely psoriatic women with a mean age of 41 years.
The survey results showed that sexuality was clearly another reason why it’s important to keep psoriasis in check. Pain and itchiness during sex, self-consciousness and embarrassment, and avoidance of dating and intimate relationships were among the most common problems the women reported.
"We really didn’t appreciate the impact psoriasis had on relationships" before the survey, Dr. Cather said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar. "The sexual impact has been underappreciated," she said.
Those problems might help explain why women with psoriasis, especially those aged younger than 35 years, tend to have fewer babies, she added. Psoriatic women also have higher rates of induced and spontaneous abortions and are more likely to have preterm and underweight births.
Some of the women surveyed said that they worried about passing psoriasis to their children. "Maybe there’s voluntary childlessness," Dr. Cather said. But when women in her practice mention they don’t want kids for fear of passing on the disease, "I answer right back, ‘You don’t have to have what you have. I can help you with it,’ " she said.
Methotrexate, acitretin, and psoralen photochemotherapy (PUVA) are contraindicated during pregnancy, but ultraviolet B (UVB) treatments are safe, said Dr. Cather. She also uses tumor necrosis factor inhibitors, which are FDA pregnancy category B agents; she prefers etanercept for its short half-life (just over 4 days) and because ob.gyns. are usually familiar with it. The Organization of Teratology Information Specialists (OTIS) keeps the etanercept and adalimumab pregnancy registries, and "there’s [been] no signal to date" for those drugs, she said.
Psoriatic women should know that the odds are with them for having a normal pregnancy, and that pregnancy is likely to help clear their skin, Dr. Cather said.
But because half of the pregnancies in the United States are unplanned, it’s important to discuss pregnancy – and psoriasis treatment during pregnancy – as part of routine care. "It’s difficult if a psoriasis patient calls you in a panic because they’re not sure their drug is safe, and not sure their doctor will let them continue it,’ she said. Some ob.gyns. are comfortable with letting women stay on their psoriasis therapy, while others want them to quit everything, even topical steroids.
"In my clinic, when a psoriasis patient gets pregnant, usually we’ve planned for it and are excited about it, and we’ve had some dialogue with the ob.gyn.," she explained.
SDEF and this news organization are owned by Frontline Medical Communications. Dr. Cather is a consultant, speaker, or researcher for AbbVie, Novartis, Leo, Janssen, Amgen, Celgene, Merck, and Pfizer.
EXPERT ANALYSIS FROM SDEF LAS VEGAS DERMATOLOGY SEMINAR
Women’s sexuality diminished by psoriasis
LAS VEGAS – Psoriasis has a negative impact on women’s sexual desire, sexual ability, and sexual relationships, according to Dr. Jennifer Cather of the Modern Dermatology-Aesthetics Center in Dallas.
Dr. Cather and her colleagues are developing a clinical tool to assess the disease’s sexual impact; as part of those efforts, they conducted 60 interviews with moderately to severely psoriatic women with a mean age of 41 years.
The survey results showed that sexuality was clearly another reason why it’s important to keep psoriasis in check. Pain and itchiness during sex, self-consciousness and embarrassment, and avoidance of dating and intimate relationships were among the most common problems the women reported.
"We really didn’t appreciate the impact psoriasis had on relationships" before the survey, Dr. Cather said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar. "The sexual impact has been underappreciated," she said.
Those problems might help explain why women with psoriasis, especially those aged younger than 35 years, tend to have fewer babies, she added. Psoriatic women also have higher rates of induced and spontaneous abortions and are more likely to have preterm and underweight births.
Some of the women surveyed said that they worried about passing psoriasis to their children. "Maybe there’s voluntary childlessness," Dr. Cather said. But when women in her practice mention they don’t want kids for fear of passing on the disease, "I answer right back, ‘You don’t have to have what you have. I can help you with it,’ " she said.
Methotrexate, acitretin, and psoralen photochemotherapy (PUVA) are contraindicated during pregnancy, but ultraviolet B (UVB) treatments are safe, said Dr. Cather. She also uses tumor necrosis factor inhibitors, which are FDA pregnancy category B agents; she prefers etanercept for its short half-life (just over 4 days) and because ob.gyns. are usually familiar with it. The Organization of Teratology Information Specialists (OTIS) keeps the etanercept and adalimumab pregnancy registries, and "there’s [been] no signal to date" for those drugs, she said.
Psoriatic women should know that the odds are with them for having a normal pregnancy, and that pregnancy is likely to help clear their skin, Dr. Cather said.
But because half of the pregnancies in the United States are unplanned, it’s important to discuss pregnancy – and psoriasis treatment during pregnancy – as part of routine care. "It’s difficult if a psoriasis patient calls you in a panic because they’re not sure their drug is safe, and not sure their doctor will let them continue it,’ she said. Some ob.gyns. are comfortable with letting women stay on their psoriasis therapy, while others want them to quit everything, even topical steroids.
"In my clinic, when a psoriasis patient gets pregnant, usually we’ve planned for it and are excited about it, and we’ve had some dialogue with the ob.gyn.," she explained.
SDEF and this news organization are owned by Frontline Medical Communications. Dr. Cather is a consultant, speaker, or researcher for AbbVie, Novartis, Leo, Janssen, Amgen, Celgene, Merck, and Pfizer.
LAS VEGAS – Psoriasis has a negative impact on women’s sexual desire, sexual ability, and sexual relationships, according to Dr. Jennifer Cather of the Modern Dermatology-Aesthetics Center in Dallas.
Dr. Cather and her colleagues are developing a clinical tool to assess the disease’s sexual impact; as part of those efforts, they conducted 60 interviews with moderately to severely psoriatic women with a mean age of 41 years.
The survey results showed that sexuality was clearly another reason why it’s important to keep psoriasis in check. Pain and itchiness during sex, self-consciousness and embarrassment, and avoidance of dating and intimate relationships were among the most common problems the women reported.
"We really didn’t appreciate the impact psoriasis had on relationships" before the survey, Dr. Cather said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar. "The sexual impact has been underappreciated," she said.
Those problems might help explain why women with psoriasis, especially those aged younger than 35 years, tend to have fewer babies, she added. Psoriatic women also have higher rates of induced and spontaneous abortions and are more likely to have preterm and underweight births.
Some of the women surveyed said that they worried about passing psoriasis to their children. "Maybe there’s voluntary childlessness," Dr. Cather said. But when women in her practice mention they don’t want kids for fear of passing on the disease, "I answer right back, ‘You don’t have to have what you have. I can help you with it,’ " she said.
Methotrexate, acitretin, and psoralen photochemotherapy (PUVA) are contraindicated during pregnancy, but ultraviolet B (UVB) treatments are safe, said Dr. Cather. She also uses tumor necrosis factor inhibitors, which are FDA pregnancy category B agents; she prefers etanercept for its short half-life (just over 4 days) and because ob.gyns. are usually familiar with it. The Organization of Teratology Information Specialists (OTIS) keeps the etanercept and adalimumab pregnancy registries, and "there’s [been] no signal to date" for those drugs, she said.
Psoriatic women should know that the odds are with them for having a normal pregnancy, and that pregnancy is likely to help clear their skin, Dr. Cather said.
But because half of the pregnancies in the United States are unplanned, it’s important to discuss pregnancy – and psoriasis treatment during pregnancy – as part of routine care. "It’s difficult if a psoriasis patient calls you in a panic because they’re not sure their drug is safe, and not sure their doctor will let them continue it,’ she said. Some ob.gyns. are comfortable with letting women stay on their psoriasis therapy, while others want them to quit everything, even topical steroids.
"In my clinic, when a psoriasis patient gets pregnant, usually we’ve planned for it and are excited about it, and we’ve had some dialogue with the ob.gyn.," she explained.
SDEF and this news organization are owned by Frontline Medical Communications. Dr. Cather is a consultant, speaker, or researcher for AbbVie, Novartis, Leo, Janssen, Amgen, Celgene, Merck, and Pfizer.
LAS VEGAS – Psoriasis has a negative impact on women’s sexual desire, sexual ability, and sexual relationships, according to Dr. Jennifer Cather of the Modern Dermatology-Aesthetics Center in Dallas.
Dr. Cather and her colleagues are developing a clinical tool to assess the disease’s sexual impact; as part of those efforts, they conducted 60 interviews with moderately to severely psoriatic women with a mean age of 41 years.
The survey results showed that sexuality was clearly another reason why it’s important to keep psoriasis in check. Pain and itchiness during sex, self-consciousness and embarrassment, and avoidance of dating and intimate relationships were among the most common problems the women reported.
"We really didn’t appreciate the impact psoriasis had on relationships" before the survey, Dr. Cather said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar. "The sexual impact has been underappreciated," she said.
Those problems might help explain why women with psoriasis, especially those aged younger than 35 years, tend to have fewer babies, she added. Psoriatic women also have higher rates of induced and spontaneous abortions and are more likely to have preterm and underweight births.
Some of the women surveyed said that they worried about passing psoriasis to their children. "Maybe there’s voluntary childlessness," Dr. Cather said. But when women in her practice mention they don’t want kids for fear of passing on the disease, "I answer right back, ‘You don’t have to have what you have. I can help you with it,’ " she said.
Methotrexate, acitretin, and psoralen photochemotherapy (PUVA) are contraindicated during pregnancy, but ultraviolet B (UVB) treatments are safe, said Dr. Cather. She also uses tumor necrosis factor inhibitors, which are FDA pregnancy category B agents; she prefers etanercept for its short half-life (just over 4 days) and because ob.gyns. are usually familiar with it. The Organization of Teratology Information Specialists (OTIS) keeps the etanercept and adalimumab pregnancy registries, and "there’s [been] no signal to date" for those drugs, she said.
Psoriatic women should know that the odds are with them for having a normal pregnancy, and that pregnancy is likely to help clear their skin, Dr. Cather said.
But because half of the pregnancies in the United States are unplanned, it’s important to discuss pregnancy – and psoriasis treatment during pregnancy – as part of routine care. "It’s difficult if a psoriasis patient calls you in a panic because they’re not sure their drug is safe, and not sure their doctor will let them continue it,’ she said. Some ob.gyns. are comfortable with letting women stay on their psoriasis therapy, while others want them to quit everything, even topical steroids.
"In my clinic, when a psoriasis patient gets pregnant, usually we’ve planned for it and are excited about it, and we’ve had some dialogue with the ob.gyn.," she explained.
SDEF and this news organization are owned by Frontline Medical Communications. Dr. Cather is a consultant, speaker, or researcher for AbbVie, Novartis, Leo, Janssen, Amgen, Celgene, Merck, and Pfizer.
EXPERT ANALYSIS FROM SDEF LAS VEGAS DERMATOLOGY SEMINAR
Wet Dressings Work for Pruritus When Other Options Fail
LAS VEGAS – Wet dressing, a technique forgotten in most places but in continual use at the Mayo Clinic for more than 80 years, knocks out intractable pruritus – whatever its cause – in children and adults, according to Dr. Mark Davis, chair of the division of clinical dermatology at the clinic in Rochester, Minn.
"It’s a simple technique that works extraordinarily well for any itchy condition from head to toe, and has virtually no side effects. It stops itching reliably, when nothing else has worked," including prednisone, methotrexate, phototherapy, and elimination diets, among other strategies, he said at Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.
Even so, "there’s remarkably little on this in the literature, and what’s published is mostly just in kids, but in adults it works brilliantly, too, particularly for atopic dermatitis. We use it when people come in itching from anything, like psoriasis," he said (J. Am. Acad. Dermatol. 2009;60:792-800).
"The commonest question [we hear from people] is ‘I’ve been going to doctors for years. Why didn’t anybody tell me about this?’ " said Dr. Davis.
If their pruritus is severe enough, patients will be admitted to the Mayo Clinic and have wet cloths applied to wherever the itch happens to be – above the waist, below the waist, the feet, or even the entire body, including the face – with a dry blanket on top if needed to ward of the chill. Patients can get up from bed for a bathroom break when the dressings are changed every 3 hours.
Topical steroids are used with the dressings up to three times a day; 1% percent hydrocortisone for the face or genitals, 0.1% or 0.05% triamcinolone elsewhere. The Mayo Clinic has never had a case of hypothalamic-pituitary-adrenal axis suppression with the technique, and insurance usually covers the cost for 3 days, Dr. Davis said.
When outpatient treatment is sufficient, pruritic patients are instructed to put on wet pajamas or long johns, or hop into the shower in dry ones, and then leave them on for 30 minutes to an hour, 3-4 times a day. Nurses, with the help of handouts and videos, teach patients how to do this, and call them every 24 hours to see how they are getting along.
Hospital patients get the same instructions at discharge. "Initially, they have to do [it] at least once a day for a number of weeks, and then they can use [the technique] on an as-needed basis, maybe once or twice a week," Dr. Davis said.
"Wet dressings went out of favor" in most places because "they are just so much trouble," he said. At present, the technique is "largely unknown," as is the reason why it works, he added.
Dr. Davis has no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.
LAS VEGAS – Wet dressing, a technique forgotten in most places but in continual use at the Mayo Clinic for more than 80 years, knocks out intractable pruritus – whatever its cause – in children and adults, according to Dr. Mark Davis, chair of the division of clinical dermatology at the clinic in Rochester, Minn.
"It’s a simple technique that works extraordinarily well for any itchy condition from head to toe, and has virtually no side effects. It stops itching reliably, when nothing else has worked," including prednisone, methotrexate, phototherapy, and elimination diets, among other strategies, he said at Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.
Even so, "there’s remarkably little on this in the literature, and what’s published is mostly just in kids, but in adults it works brilliantly, too, particularly for atopic dermatitis. We use it when people come in itching from anything, like psoriasis," he said (J. Am. Acad. Dermatol. 2009;60:792-800).
"The commonest question [we hear from people] is ‘I’ve been going to doctors for years. Why didn’t anybody tell me about this?’ " said Dr. Davis.
If their pruritus is severe enough, patients will be admitted to the Mayo Clinic and have wet cloths applied to wherever the itch happens to be – above the waist, below the waist, the feet, or even the entire body, including the face – with a dry blanket on top if needed to ward of the chill. Patients can get up from bed for a bathroom break when the dressings are changed every 3 hours.
Topical steroids are used with the dressings up to three times a day; 1% percent hydrocortisone for the face or genitals, 0.1% or 0.05% triamcinolone elsewhere. The Mayo Clinic has never had a case of hypothalamic-pituitary-adrenal axis suppression with the technique, and insurance usually covers the cost for 3 days, Dr. Davis said.
When outpatient treatment is sufficient, pruritic patients are instructed to put on wet pajamas or long johns, or hop into the shower in dry ones, and then leave them on for 30 minutes to an hour, 3-4 times a day. Nurses, with the help of handouts and videos, teach patients how to do this, and call them every 24 hours to see how they are getting along.
Hospital patients get the same instructions at discharge. "Initially, they have to do [it] at least once a day for a number of weeks, and then they can use [the technique] on an as-needed basis, maybe once or twice a week," Dr. Davis said.
"Wet dressings went out of favor" in most places because "they are just so much trouble," he said. At present, the technique is "largely unknown," as is the reason why it works, he added.
Dr. Davis has no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.
LAS VEGAS – Wet dressing, a technique forgotten in most places but in continual use at the Mayo Clinic for more than 80 years, knocks out intractable pruritus – whatever its cause – in children and adults, according to Dr. Mark Davis, chair of the division of clinical dermatology at the clinic in Rochester, Minn.
"It’s a simple technique that works extraordinarily well for any itchy condition from head to toe, and has virtually no side effects. It stops itching reliably, when nothing else has worked," including prednisone, methotrexate, phototherapy, and elimination diets, among other strategies, he said at Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.
Even so, "there’s remarkably little on this in the literature, and what’s published is mostly just in kids, but in adults it works brilliantly, too, particularly for atopic dermatitis. We use it when people come in itching from anything, like psoriasis," he said (J. Am. Acad. Dermatol. 2009;60:792-800).
"The commonest question [we hear from people] is ‘I’ve been going to doctors for years. Why didn’t anybody tell me about this?’ " said Dr. Davis.
If their pruritus is severe enough, patients will be admitted to the Mayo Clinic and have wet cloths applied to wherever the itch happens to be – above the waist, below the waist, the feet, or even the entire body, including the face – with a dry blanket on top if needed to ward of the chill. Patients can get up from bed for a bathroom break when the dressings are changed every 3 hours.
Topical steroids are used with the dressings up to three times a day; 1% percent hydrocortisone for the face or genitals, 0.1% or 0.05% triamcinolone elsewhere. The Mayo Clinic has never had a case of hypothalamic-pituitary-adrenal axis suppression with the technique, and insurance usually covers the cost for 3 days, Dr. Davis said.
When outpatient treatment is sufficient, pruritic patients are instructed to put on wet pajamas or long johns, or hop into the shower in dry ones, and then leave them on for 30 minutes to an hour, 3-4 times a day. Nurses, with the help of handouts and videos, teach patients how to do this, and call them every 24 hours to see how they are getting along.
Hospital patients get the same instructions at discharge. "Initially, they have to do [it] at least once a day for a number of weeks, and then they can use [the technique] on an as-needed basis, maybe once or twice a week," Dr. Davis said.
"Wet dressings went out of favor" in most places because "they are just so much trouble," he said. At present, the technique is "largely unknown," as is the reason why it works, he added.
Dr. Davis has no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.
AT SDEF LAS VEGAS DERMATOLOGY SEMINAR
Wet dressings work for pruritus when other options fail
LAS VEGAS – Wet dressing, a technique forgotten in most places but in continual use at the Mayo Clinic for more than 80 years, knocks out intractable pruritus – whatever its cause – in children and adults, according to Dr. Mark Davis, chair of the division of clinical dermatology at the clinic in Rochester, Minn.
"It’s a simple technique that works extraordinarily well for any itchy condition from head to toe, and has virtually no side effects. It stops itching reliably, when nothing else has worked," including prednisone, methotrexate, phototherapy, and elimination diets, among other strategies, he said at Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.
Even so, "there’s remarkably little on this in the literature, and what’s published is mostly just in kids, but in adults it works brilliantly, too, particularly for atopic dermatitis. We use it when people come in itching from anything, like psoriasis," he said (J. Am. Acad. Dermatol. 2009;60:792-800).
"The commonest question [we hear from people] is ‘I’ve been going to doctors for years. Why didn’t anybody tell me about this?’ " said Dr. Davis.
If their pruritus is severe enough, patients will be admitted to the Mayo Clinic and have wet cloths applied to wherever the itch happens to be – above the waist, below the waist, the feet, or even the entire body, including the face – with a dry blanket on top if needed to ward of the chill. Patients can get up from bed for a bathroom break when the dressings are changed every 3 hours.
Topical steroids are used with the dressings up to three times a day; 1% percent hydrocortisone for the face or genitals, 0.1% or 0.05% triamcinolone elsewhere. The Mayo Clinic has never had a case of hypothalamic-pituitary-adrenal axis suppression with the technique, and insurance usually covers the cost for 3 days, Dr. Davis said.
When outpatient treatment is sufficient, pruritic patients are instructed to put on wet pajamas or long johns, or hop into the shower in dry ones, and then leave them on for 30 minutes to an hour, 3-4 times a day. Nurses, with the help of handouts and videos, teach patients how to do this, and call them every 24 hours to see how they are getting along.
Hospital patients get the same instructions at discharge. "Initially, they have to do [it] at least once a day for a number of weeks, and then they can use [the technique] on an as-needed basis, maybe once or twice a week," Dr. Davis said.
"Wet dressings went out of favor" in most places because "they are just so much trouble," he said. At present, the technique is "largely unknown," as is the reason why it works, he added.
Dr. Davis has no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.
LAS VEGAS – Wet dressing, a technique forgotten in most places but in continual use at the Mayo Clinic for more than 80 years, knocks out intractable pruritus – whatever its cause – in children and adults, according to Dr. Mark Davis, chair of the division of clinical dermatology at the clinic in Rochester, Minn.
"It’s a simple technique that works extraordinarily well for any itchy condition from head to toe, and has virtually no side effects. It stops itching reliably, when nothing else has worked," including prednisone, methotrexate, phototherapy, and elimination diets, among other strategies, he said at Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.
Even so, "there’s remarkably little on this in the literature, and what’s published is mostly just in kids, but in adults it works brilliantly, too, particularly for atopic dermatitis. We use it when people come in itching from anything, like psoriasis," he said (J. Am. Acad. Dermatol. 2009;60:792-800).
"The commonest question [we hear from people] is ‘I’ve been going to doctors for years. Why didn’t anybody tell me about this?’ " said Dr. Davis.
If their pruritus is severe enough, patients will be admitted to the Mayo Clinic and have wet cloths applied to wherever the itch happens to be – above the waist, below the waist, the feet, or even the entire body, including the face – with a dry blanket on top if needed to ward of the chill. Patients can get up from bed for a bathroom break when the dressings are changed every 3 hours.
Topical steroids are used with the dressings up to three times a day; 1% percent hydrocortisone for the face or genitals, 0.1% or 0.05% triamcinolone elsewhere. The Mayo Clinic has never had a case of hypothalamic-pituitary-adrenal axis suppression with the technique, and insurance usually covers the cost for 3 days, Dr. Davis said.
When outpatient treatment is sufficient, pruritic patients are instructed to put on wet pajamas or long johns, or hop into the shower in dry ones, and then leave them on for 30 minutes to an hour, 3-4 times a day. Nurses, with the help of handouts and videos, teach patients how to do this, and call them every 24 hours to see how they are getting along.
Hospital patients get the same instructions at discharge. "Initially, they have to do [it] at least once a day for a number of weeks, and then they can use [the technique] on an as-needed basis, maybe once or twice a week," Dr. Davis said.
"Wet dressings went out of favor" in most places because "they are just so much trouble," he said. At present, the technique is "largely unknown," as is the reason why it works, he added.
Dr. Davis has no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.
LAS VEGAS – Wet dressing, a technique forgotten in most places but in continual use at the Mayo Clinic for more than 80 years, knocks out intractable pruritus – whatever its cause – in children and adults, according to Dr. Mark Davis, chair of the division of clinical dermatology at the clinic in Rochester, Minn.
"It’s a simple technique that works extraordinarily well for any itchy condition from head to toe, and has virtually no side effects. It stops itching reliably, when nothing else has worked," including prednisone, methotrexate, phototherapy, and elimination diets, among other strategies, he said at Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.
Even so, "there’s remarkably little on this in the literature, and what’s published is mostly just in kids, but in adults it works brilliantly, too, particularly for atopic dermatitis. We use it when people come in itching from anything, like psoriasis," he said (J. Am. Acad. Dermatol. 2009;60:792-800).
"The commonest question [we hear from people] is ‘I’ve been going to doctors for years. Why didn’t anybody tell me about this?’ " said Dr. Davis.
If their pruritus is severe enough, patients will be admitted to the Mayo Clinic and have wet cloths applied to wherever the itch happens to be – above the waist, below the waist, the feet, or even the entire body, including the face – with a dry blanket on top if needed to ward of the chill. Patients can get up from bed for a bathroom break when the dressings are changed every 3 hours.
Topical steroids are used with the dressings up to three times a day; 1% percent hydrocortisone for the face or genitals, 0.1% or 0.05% triamcinolone elsewhere. The Mayo Clinic has never had a case of hypothalamic-pituitary-adrenal axis suppression with the technique, and insurance usually covers the cost for 3 days, Dr. Davis said.
When outpatient treatment is sufficient, pruritic patients are instructed to put on wet pajamas or long johns, or hop into the shower in dry ones, and then leave them on for 30 minutes to an hour, 3-4 times a day. Nurses, with the help of handouts and videos, teach patients how to do this, and call them every 24 hours to see how they are getting along.
Hospital patients get the same instructions at discharge. "Initially, they have to do [it] at least once a day for a number of weeks, and then they can use [the technique] on an as-needed basis, maybe once or twice a week," Dr. Davis said.
"Wet dressings went out of favor" in most places because "they are just so much trouble," he said. At present, the technique is "largely unknown," as is the reason why it works, he added.
Dr. Davis has no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.
AT SDEF LAS VEGAS DERMATOLOGY SEMINAR
AAFP votes to ban energy drink sales to kids
SAN DIEGO – The American Academy of Family Physicians will push the federal government to ban on the sale of energy drinks – caffeinated beverages that come in fizzy cans or small twist-cap bottle syrups – to kids under 18 years old, following a vote to do so by its Congress of Delegates.
Pitched largely to kids, "energy drinks are dangerous to youth and can lead to dehydration, particularly when consumed with alcohol," a not uncommon practice among minors. The academy will also work with the Food and Drug Administration to oppose handing out free samples to kids and establish specific definitions of stimulant drinks.
Delegates were following the news reports of the harm done by these drinks, which have been associated with thousands of visits by minors to the emergency department, and some deaths, mostly among children who overindulged on energy drinks. The beverages typically contain perhaps 200 mg of caffeine – but sometimes much more – plus herbs and other ingredients added to boost stimulating effects. In comparison, a 16 oz. Starbuck’s coffee comes with a 330 mg caffeine bolus.
The American Academy of Pediatrics has already come out against the drinks, and a few states are considering bans on sales to those under age 18 years.
The problem in New York, though, where AAFP’s resolution originated, is that legislators "believe this is a federal issue, an FDA issue," said Vito Grasso, executive vice-president of the state’s AAFP chapter. Meanwhile, N.Y. doctors are seeing heart issues, hyperactivity, and exacerbations of asthma and other chronic conditions in children because of the drinks, Mr. Grasso said.
AAFP is likely to draft legislation to remind the FDA that it has jurisdiction in the matter and can demand that companies fully disclose what the drinks contain, but AAFP delegates agreed with their N.Y. colleagues that there’s already enough evidence to ban the drinks for kids.
The move was just 1 of more than 50 resolutions tackled by AAFP delegates. None matched the fireworks of 2012’s vote to support gay marriage, but delegates considered some controversial topics.
Gun violence was one of those. Attendees voted to name it "a significant public health problem" that needs "further research."
That wasn’t as light-footed as it sounds. Worried that scientific findings might be used to support firearm limits, gun interests have kept the federal government from funding gun violence studies for almost 20 years, AAFP board chair Dr. Jeffrey Cain explained later.
The de-facto ban was relaxed a bit after a troubled, assault-weapon–wielding 20-year-old killed his mother and murdered 20 kindergarten and first grade students, and six teachers and administrators trying to protect them, at Sandy Hook Elementary School in Newtown, Conn., in December 2012. Delegates decided it’s time to get behind federal dollars to find how to stop gun murder in the United States and generate the data needed to cut through the country’s indecision on gun access.
Delegates voted down, however, calls by delegates from Washington and Oregon for mandatory background checks and tracking of all gun sales and transfers; delegates decided the issues were too "divisive."
Gun violence "is now recognized by our Academy as an issue of public health," just like using seatbelts in cars. Beyond that, though, "our members’ political views span the full spectrum, like the citizens of America," Dr. Cain said.
Delegates also decided that AAFP’s current gun policy addresses the intent of the Northwest measures, including, as it does, opposition to civilian ownership of military assault weapons, backing of doctors’ rights to ask gun owners about firearm safety in their homes, and support of background checks to keep guns out of the hands of criminals and people with mental illness.
Other measures
Guns and energy drinks weren’t the only things on AAFP delegates’ minds.
The group, which decides academy legislative and policy priorities, tackled more than 50 resolutions. Among them, it directed the academy to do the following:
• Push for automated electronic defibrillators in high schools.
• Work to ensure that "relative value unit" compensation models aren’t used to shortchange family doctors’ paychecks.
• Allow family medicine residents to prescribe for Medicaid patients.
• Stop states from adding extra CME requirements beyond what boards require.
• Consider legislative fixes so doctors can keep their license protections when helping sports teams and disaster victims out of state.
Delegates also revisited gay marriage. Oklahoma wanted the academy to take a neutral position on the issue, arguing that, like abortion and gun control, the issue is too divisive for members and goes beyond the medical issues AAFP should focus on.
Delegates didn’t go for it: "To go back on what the Congress of Delegates decided last year would be to make a divisive issue only more contentious. The testimony and research by the American College of Obstetricians and Gynecologists made it clear that marriage is a key to the access to health care. The adoption of the proposed resolution would say that the AAFP no longer believes that civil marriage is a health issue. In the final analysis ... the Congress of Delegates did not adopt the resolution to support civil [same-gender] marriage, but to serve the health of our members, our patients, and our communities," wrote the resolution committee, winning the day.
Medical marijuana came up, too.
New York asked delegates to fight state approval of smoked cannabis, arguing that it’s the business of the FDA to regulate drugs, not state legislators and that smoking pot probably hurts the lungs. AAFP’s N.Y. members are working stop the Empire State from approving medical marijuana, and wanted the academy’s help.
After testimony about marijuana’s benefits for sick people, delegates decided to sidestep the issue and vote instead for AAFP research and "expressing concerns" about the safety of smoking it.
The academy was also directed to take a few steps on women’s health issues.
Among them, it will try to stop the Centers for Medicare & Medicaid Services from requiring abnormal pap smears before paying for HPV screening. The American Society for Colposcopy and Cervical Pathology wants doctors to screen high-risk women over age 29 years for HPV during routine Pap smears, whatever their prior results. Delegates voted that payment guidelines need to match those of experts. Also, AAFP will also now support IUDs as first-line contraceptives for most women, and work to end prior approval for FDA-cleared contraceptive devices. The Affordable Care Act requires their coverage, so requiring prior authorization doesn’t make any sense, California and Texas delegates said in their resolutions.
The academy is going to look into pushing for OTC birth control pills, as well, but delegates didn’t want it to support OTC access without more investigation. Some worried that insurance companies won’t cover OTC birth control, and others that women might "stop visiting their family physicians if they no longer had to rely on them for birth control prescriptions."
Putting the ‘primary’ back into primary care education
Medical schools were the subject of three strong resolutions from New Hampshire delegates tired of hearing about professors who shoot down primary care as a career option.
Delegates didn’t like that either and voted for AAFP to poll new residents about what medical school faculty said regarding family care, and to figure out how many medical school graduates go into primary care each year and how many are still at it 5 years later.
The big hammer, though, was a vote from delegates for the academy to consider a push to link medical school accreditation and CMS education reimbursements to the number of graduates who go into primary care.
A better way for rural EDs
The AAFP endorsed Comprehensive Advanced Life Support (CALS) training as "an appropriate advanced life support course for" rural physicians and will consider it as an alternative to Advanced Trauma Life Support (ATLS) for low-level state trauma designation.
That’s not a trivial decision for rural emergency departments (EDs), where a lone family physician, physician assistant, or nurse practitioner is on the hook to handle anything that comes through the door, without help from specialists.
CALS was designed in Minnesota 20 years ago to help providers in rural EDs do that. "Other ED courses focus on specific emergencies. We compressed them, eliminated the redundancies, and added psychiatric, neurologic, burn, and other emergencies the other courses don’t cover," said Dr. Paul Van Gorp, a family practitioner in Long Prairie, Minn., and CALS board chair.
"It’s been very successful. We’ve presented CALS in nine states and several countries; people who have taken it, many from remote places like Alaska, have wonderful things to say about it, but not every state recognizes CALS as an acceptable route to qualify as a level 3 or 4 trauma center," he said.
In most states, "the only route to trauma level designation is ATLS, but trauma is just a small part of what we see," he said.
AAFP’s recognition will add heft to efforts to get states to recognize CALS as an alternative.
The course has 2 days of scenario-based training, a half-day trauma module that meets requirements for state trauma designation, and a day-long benchmark skills lab. A sheep is killed in the lab, but "we recognize that there’re a lot of people opposed to us using animals in this way, so we developed" an alternative that "entirely uses mannequins as a substitute," Dr. Van Gorp said.
The course comes with an exhaustive electronic reference manual to freshen up when the ambulance calls in. It’s a reassuring resource in places where "you go through an emergency and get pretty comfortable with it, but don’t see it again for 5 years," he said.
SAN DIEGO – The American Academy of Family Physicians will push the federal government to ban on the sale of energy drinks – caffeinated beverages that come in fizzy cans or small twist-cap bottle syrups – to kids under 18 years old, following a vote to do so by its Congress of Delegates.
Pitched largely to kids, "energy drinks are dangerous to youth and can lead to dehydration, particularly when consumed with alcohol," a not uncommon practice among minors. The academy will also work with the Food and Drug Administration to oppose handing out free samples to kids and establish specific definitions of stimulant drinks.
Delegates were following the news reports of the harm done by these drinks, which have been associated with thousands of visits by minors to the emergency department, and some deaths, mostly among children who overindulged on energy drinks. The beverages typically contain perhaps 200 mg of caffeine – but sometimes much more – plus herbs and other ingredients added to boost stimulating effects. In comparison, a 16 oz. Starbuck’s coffee comes with a 330 mg caffeine bolus.
The American Academy of Pediatrics has already come out against the drinks, and a few states are considering bans on sales to those under age 18 years.
The problem in New York, though, where AAFP’s resolution originated, is that legislators "believe this is a federal issue, an FDA issue," said Vito Grasso, executive vice-president of the state’s AAFP chapter. Meanwhile, N.Y. doctors are seeing heart issues, hyperactivity, and exacerbations of asthma and other chronic conditions in children because of the drinks, Mr. Grasso said.
AAFP is likely to draft legislation to remind the FDA that it has jurisdiction in the matter and can demand that companies fully disclose what the drinks contain, but AAFP delegates agreed with their N.Y. colleagues that there’s already enough evidence to ban the drinks for kids.
The move was just 1 of more than 50 resolutions tackled by AAFP delegates. None matched the fireworks of 2012’s vote to support gay marriage, but delegates considered some controversial topics.
Gun violence was one of those. Attendees voted to name it "a significant public health problem" that needs "further research."
That wasn’t as light-footed as it sounds. Worried that scientific findings might be used to support firearm limits, gun interests have kept the federal government from funding gun violence studies for almost 20 years, AAFP board chair Dr. Jeffrey Cain explained later.
The de-facto ban was relaxed a bit after a troubled, assault-weapon–wielding 20-year-old killed his mother and murdered 20 kindergarten and first grade students, and six teachers and administrators trying to protect them, at Sandy Hook Elementary School in Newtown, Conn., in December 2012. Delegates decided it’s time to get behind federal dollars to find how to stop gun murder in the United States and generate the data needed to cut through the country’s indecision on gun access.
Delegates voted down, however, calls by delegates from Washington and Oregon for mandatory background checks and tracking of all gun sales and transfers; delegates decided the issues were too "divisive."
Gun violence "is now recognized by our Academy as an issue of public health," just like using seatbelts in cars. Beyond that, though, "our members’ political views span the full spectrum, like the citizens of America," Dr. Cain said.
Delegates also decided that AAFP’s current gun policy addresses the intent of the Northwest measures, including, as it does, opposition to civilian ownership of military assault weapons, backing of doctors’ rights to ask gun owners about firearm safety in their homes, and support of background checks to keep guns out of the hands of criminals and people with mental illness.
Other measures
Guns and energy drinks weren’t the only things on AAFP delegates’ minds.
The group, which decides academy legislative and policy priorities, tackled more than 50 resolutions. Among them, it directed the academy to do the following:
• Push for automated electronic defibrillators in high schools.
• Work to ensure that "relative value unit" compensation models aren’t used to shortchange family doctors’ paychecks.
• Allow family medicine residents to prescribe for Medicaid patients.
• Stop states from adding extra CME requirements beyond what boards require.
• Consider legislative fixes so doctors can keep their license protections when helping sports teams and disaster victims out of state.
Delegates also revisited gay marriage. Oklahoma wanted the academy to take a neutral position on the issue, arguing that, like abortion and gun control, the issue is too divisive for members and goes beyond the medical issues AAFP should focus on.
Delegates didn’t go for it: "To go back on what the Congress of Delegates decided last year would be to make a divisive issue only more contentious. The testimony and research by the American College of Obstetricians and Gynecologists made it clear that marriage is a key to the access to health care. The adoption of the proposed resolution would say that the AAFP no longer believes that civil marriage is a health issue. In the final analysis ... the Congress of Delegates did not adopt the resolution to support civil [same-gender] marriage, but to serve the health of our members, our patients, and our communities," wrote the resolution committee, winning the day.
Medical marijuana came up, too.
New York asked delegates to fight state approval of smoked cannabis, arguing that it’s the business of the FDA to regulate drugs, not state legislators and that smoking pot probably hurts the lungs. AAFP’s N.Y. members are working stop the Empire State from approving medical marijuana, and wanted the academy’s help.
After testimony about marijuana’s benefits for sick people, delegates decided to sidestep the issue and vote instead for AAFP research and "expressing concerns" about the safety of smoking it.
The academy was also directed to take a few steps on women’s health issues.
Among them, it will try to stop the Centers for Medicare & Medicaid Services from requiring abnormal pap smears before paying for HPV screening. The American Society for Colposcopy and Cervical Pathology wants doctors to screen high-risk women over age 29 years for HPV during routine Pap smears, whatever their prior results. Delegates voted that payment guidelines need to match those of experts. Also, AAFP will also now support IUDs as first-line contraceptives for most women, and work to end prior approval for FDA-cleared contraceptive devices. The Affordable Care Act requires their coverage, so requiring prior authorization doesn’t make any sense, California and Texas delegates said in their resolutions.
The academy is going to look into pushing for OTC birth control pills, as well, but delegates didn’t want it to support OTC access without more investigation. Some worried that insurance companies won’t cover OTC birth control, and others that women might "stop visiting their family physicians if they no longer had to rely on them for birth control prescriptions."
Putting the ‘primary’ back into primary care education
Medical schools were the subject of three strong resolutions from New Hampshire delegates tired of hearing about professors who shoot down primary care as a career option.
Delegates didn’t like that either and voted for AAFP to poll new residents about what medical school faculty said regarding family care, and to figure out how many medical school graduates go into primary care each year and how many are still at it 5 years later.
The big hammer, though, was a vote from delegates for the academy to consider a push to link medical school accreditation and CMS education reimbursements to the number of graduates who go into primary care.
A better way for rural EDs
The AAFP endorsed Comprehensive Advanced Life Support (CALS) training as "an appropriate advanced life support course for" rural physicians and will consider it as an alternative to Advanced Trauma Life Support (ATLS) for low-level state trauma designation.
That’s not a trivial decision for rural emergency departments (EDs), where a lone family physician, physician assistant, or nurse practitioner is on the hook to handle anything that comes through the door, without help from specialists.
CALS was designed in Minnesota 20 years ago to help providers in rural EDs do that. "Other ED courses focus on specific emergencies. We compressed them, eliminated the redundancies, and added psychiatric, neurologic, burn, and other emergencies the other courses don’t cover," said Dr. Paul Van Gorp, a family practitioner in Long Prairie, Minn., and CALS board chair.
"It’s been very successful. We’ve presented CALS in nine states and several countries; people who have taken it, many from remote places like Alaska, have wonderful things to say about it, but not every state recognizes CALS as an acceptable route to qualify as a level 3 or 4 trauma center," he said.
In most states, "the only route to trauma level designation is ATLS, but trauma is just a small part of what we see," he said.
AAFP’s recognition will add heft to efforts to get states to recognize CALS as an alternative.
The course has 2 days of scenario-based training, a half-day trauma module that meets requirements for state trauma designation, and a day-long benchmark skills lab. A sheep is killed in the lab, but "we recognize that there’re a lot of people opposed to us using animals in this way, so we developed" an alternative that "entirely uses mannequins as a substitute," Dr. Van Gorp said.
The course comes with an exhaustive electronic reference manual to freshen up when the ambulance calls in. It’s a reassuring resource in places where "you go through an emergency and get pretty comfortable with it, but don’t see it again for 5 years," he said.
SAN DIEGO – The American Academy of Family Physicians will push the federal government to ban on the sale of energy drinks – caffeinated beverages that come in fizzy cans or small twist-cap bottle syrups – to kids under 18 years old, following a vote to do so by its Congress of Delegates.
Pitched largely to kids, "energy drinks are dangerous to youth and can lead to dehydration, particularly when consumed with alcohol," a not uncommon practice among minors. The academy will also work with the Food and Drug Administration to oppose handing out free samples to kids and establish specific definitions of stimulant drinks.
Delegates were following the news reports of the harm done by these drinks, which have been associated with thousands of visits by minors to the emergency department, and some deaths, mostly among children who overindulged on energy drinks. The beverages typically contain perhaps 200 mg of caffeine – but sometimes much more – plus herbs and other ingredients added to boost stimulating effects. In comparison, a 16 oz. Starbuck’s coffee comes with a 330 mg caffeine bolus.
The American Academy of Pediatrics has already come out against the drinks, and a few states are considering bans on sales to those under age 18 years.
The problem in New York, though, where AAFP’s resolution originated, is that legislators "believe this is a federal issue, an FDA issue," said Vito Grasso, executive vice-president of the state’s AAFP chapter. Meanwhile, N.Y. doctors are seeing heart issues, hyperactivity, and exacerbations of asthma and other chronic conditions in children because of the drinks, Mr. Grasso said.
AAFP is likely to draft legislation to remind the FDA that it has jurisdiction in the matter and can demand that companies fully disclose what the drinks contain, but AAFP delegates agreed with their N.Y. colleagues that there’s already enough evidence to ban the drinks for kids.
The move was just 1 of more than 50 resolutions tackled by AAFP delegates. None matched the fireworks of 2012’s vote to support gay marriage, but delegates considered some controversial topics.
Gun violence was one of those. Attendees voted to name it "a significant public health problem" that needs "further research."
That wasn’t as light-footed as it sounds. Worried that scientific findings might be used to support firearm limits, gun interests have kept the federal government from funding gun violence studies for almost 20 years, AAFP board chair Dr. Jeffrey Cain explained later.
The de-facto ban was relaxed a bit after a troubled, assault-weapon–wielding 20-year-old killed his mother and murdered 20 kindergarten and first grade students, and six teachers and administrators trying to protect them, at Sandy Hook Elementary School in Newtown, Conn., in December 2012. Delegates decided it’s time to get behind federal dollars to find how to stop gun murder in the United States and generate the data needed to cut through the country’s indecision on gun access.
Delegates voted down, however, calls by delegates from Washington and Oregon for mandatory background checks and tracking of all gun sales and transfers; delegates decided the issues were too "divisive."
Gun violence "is now recognized by our Academy as an issue of public health," just like using seatbelts in cars. Beyond that, though, "our members’ political views span the full spectrum, like the citizens of America," Dr. Cain said.
Delegates also decided that AAFP’s current gun policy addresses the intent of the Northwest measures, including, as it does, opposition to civilian ownership of military assault weapons, backing of doctors’ rights to ask gun owners about firearm safety in their homes, and support of background checks to keep guns out of the hands of criminals and people with mental illness.
Other measures
Guns and energy drinks weren’t the only things on AAFP delegates’ minds.
The group, which decides academy legislative and policy priorities, tackled more than 50 resolutions. Among them, it directed the academy to do the following:
• Push for automated electronic defibrillators in high schools.
• Work to ensure that "relative value unit" compensation models aren’t used to shortchange family doctors’ paychecks.
• Allow family medicine residents to prescribe for Medicaid patients.
• Stop states from adding extra CME requirements beyond what boards require.
• Consider legislative fixes so doctors can keep their license protections when helping sports teams and disaster victims out of state.
Delegates also revisited gay marriage. Oklahoma wanted the academy to take a neutral position on the issue, arguing that, like abortion and gun control, the issue is too divisive for members and goes beyond the medical issues AAFP should focus on.
Delegates didn’t go for it: "To go back on what the Congress of Delegates decided last year would be to make a divisive issue only more contentious. The testimony and research by the American College of Obstetricians and Gynecologists made it clear that marriage is a key to the access to health care. The adoption of the proposed resolution would say that the AAFP no longer believes that civil marriage is a health issue. In the final analysis ... the Congress of Delegates did not adopt the resolution to support civil [same-gender] marriage, but to serve the health of our members, our patients, and our communities," wrote the resolution committee, winning the day.
Medical marijuana came up, too.
New York asked delegates to fight state approval of smoked cannabis, arguing that it’s the business of the FDA to regulate drugs, not state legislators and that smoking pot probably hurts the lungs. AAFP’s N.Y. members are working stop the Empire State from approving medical marijuana, and wanted the academy’s help.
After testimony about marijuana’s benefits for sick people, delegates decided to sidestep the issue and vote instead for AAFP research and "expressing concerns" about the safety of smoking it.
The academy was also directed to take a few steps on women’s health issues.
Among them, it will try to stop the Centers for Medicare & Medicaid Services from requiring abnormal pap smears before paying for HPV screening. The American Society for Colposcopy and Cervical Pathology wants doctors to screen high-risk women over age 29 years for HPV during routine Pap smears, whatever their prior results. Delegates voted that payment guidelines need to match those of experts. Also, AAFP will also now support IUDs as first-line contraceptives for most women, and work to end prior approval for FDA-cleared contraceptive devices. The Affordable Care Act requires their coverage, so requiring prior authorization doesn’t make any sense, California and Texas delegates said in their resolutions.
The academy is going to look into pushing for OTC birth control pills, as well, but delegates didn’t want it to support OTC access without more investigation. Some worried that insurance companies won’t cover OTC birth control, and others that women might "stop visiting their family physicians if they no longer had to rely on them for birth control prescriptions."
Putting the ‘primary’ back into primary care education
Medical schools were the subject of three strong resolutions from New Hampshire delegates tired of hearing about professors who shoot down primary care as a career option.
Delegates didn’t like that either and voted for AAFP to poll new residents about what medical school faculty said regarding family care, and to figure out how many medical school graduates go into primary care each year and how many are still at it 5 years later.
The big hammer, though, was a vote from delegates for the academy to consider a push to link medical school accreditation and CMS education reimbursements to the number of graduates who go into primary care.
A better way for rural EDs
The AAFP endorsed Comprehensive Advanced Life Support (CALS) training as "an appropriate advanced life support course for" rural physicians and will consider it as an alternative to Advanced Trauma Life Support (ATLS) for low-level state trauma designation.
That’s not a trivial decision for rural emergency departments (EDs), where a lone family physician, physician assistant, or nurse practitioner is on the hook to handle anything that comes through the door, without help from specialists.
CALS was designed in Minnesota 20 years ago to help providers in rural EDs do that. "Other ED courses focus on specific emergencies. We compressed them, eliminated the redundancies, and added psychiatric, neurologic, burn, and other emergencies the other courses don’t cover," said Dr. Paul Van Gorp, a family practitioner in Long Prairie, Minn., and CALS board chair.
"It’s been very successful. We’ve presented CALS in nine states and several countries; people who have taken it, many from remote places like Alaska, have wonderful things to say about it, but not every state recognizes CALS as an acceptable route to qualify as a level 3 or 4 trauma center," he said.
In most states, "the only route to trauma level designation is ATLS, but trauma is just a small part of what we see," he said.
AAFP’s recognition will add heft to efforts to get states to recognize CALS as an alternative.
The course has 2 days of scenario-based training, a half-day trauma module that meets requirements for state trauma designation, and a day-long benchmark skills lab. A sheep is killed in the lab, but "we recognize that there’re a lot of people opposed to us using animals in this way, so we developed" an alternative that "entirely uses mannequins as a substitute," Dr. Van Gorp said.
The course comes with an exhaustive electronic reference manual to freshen up when the ambulance calls in. It’s a reassuring resource in places where "you go through an emergency and get pretty comfortable with it, but don’t see it again for 5 years," he said.
AT THE AAFP 2013 CONGRESS OF DELEGATES
Oral contrast rarely needed before CT scans of adults with acute abdomen
SEATTLE – Oral contrast is almost always unnecessary when performing a CT scan to work up adults with acute abdomens. Further, intravenous contrast is needed only when vascular causes of pain are suspected, according to Dr. Phillips Perera, a clinical associate professor of emergency medicine at Stanford (Calif.) University Medical Center.
As with everything in medicine, there are rare exceptions to this advice, he said. Oral contrast can be helpful to confirm the presence of a fistula in a postcolectomy patient, for example.
With the growth of endovascular repair of abdominal aortic aneurysms, patients with procedural complications including leaks and postop pain are increasingly presenting in emergency departments. Intravenous contrast is needed in those cases, and "more and more of these patients will be coming into the emergency department in the next few years," he said.
Forgoing oral contrast "allows us to get our patients through the emergency department much faster, and we don’t lose [diagnostic] accuracy." It also reduces radiation exposure, because noncontrast CT studies take less time, he said. The sensitivity of noncontrast CT is 93% for detecting acute appendicitis, with a specificity of 96% (Ann. Emerg. Med. 2010;55:51-59).
Recent studies indicate noncontrast CTs work well to diagnose most causes of acute abdominal pain in adults, including appendicitis, diverticulitis, kidney stones, and large ovarian cysts at risk for ovarian torsion (J. Endourol. 2008;22:2441-5).
"You only [lose] about two percentage points" on diagnostic accuracy by forgoing contrast, and the difference in one large study (World J. Surg. 2010;34:699-703) "was not statistically significant, which I think is the most important thing," Dr. Perera said in a literature review discussion at the annual meeting of the American College of Emergency Physicians.
Radiologists still require emergency physicians in some places "to make patients drink those big bottles" of contrast. "It takes about 6 hours to drink that contrast and let it pass through; that bed is pretty much done for your shift," he observed.
"We would like not to have to do IV contrast [too], but we need to move with radiologists" on that decision, and the literature has not reached that conclusion, he said. Meanwhile, "if you’re thinking about mesenteric ischemia, thrombosis, abdominal aortic aneurysm" or some other vascular cause of abdominal pain, "you want to consider giving IV contrast."
Pancreatic and intestinal fluid alone adequately opacifies the lumen of the bowel, enabling visualization of bowel loops and abrupt, diagnostic changes in lumen caliber, he said.
Alternatively, IV contrast is needed to detect bowel ischemia. The wall of ischemic intestines will not take up contrast, and the twisting of mesenteric vessels will often be apparent.
Dr. Perera reported having no relevant conflicts of interest.
SEATTLE – Oral contrast is almost always unnecessary when performing a CT scan to work up adults with acute abdomens. Further, intravenous contrast is needed only when vascular causes of pain are suspected, according to Dr. Phillips Perera, a clinical associate professor of emergency medicine at Stanford (Calif.) University Medical Center.
As with everything in medicine, there are rare exceptions to this advice, he said. Oral contrast can be helpful to confirm the presence of a fistula in a postcolectomy patient, for example.
With the growth of endovascular repair of abdominal aortic aneurysms, patients with procedural complications including leaks and postop pain are increasingly presenting in emergency departments. Intravenous contrast is needed in those cases, and "more and more of these patients will be coming into the emergency department in the next few years," he said.
Forgoing oral contrast "allows us to get our patients through the emergency department much faster, and we don’t lose [diagnostic] accuracy." It also reduces radiation exposure, because noncontrast CT studies take less time, he said. The sensitivity of noncontrast CT is 93% for detecting acute appendicitis, with a specificity of 96% (Ann. Emerg. Med. 2010;55:51-59).
Recent studies indicate noncontrast CTs work well to diagnose most causes of acute abdominal pain in adults, including appendicitis, diverticulitis, kidney stones, and large ovarian cysts at risk for ovarian torsion (J. Endourol. 2008;22:2441-5).
"You only [lose] about two percentage points" on diagnostic accuracy by forgoing contrast, and the difference in one large study (World J. Surg. 2010;34:699-703) "was not statistically significant, which I think is the most important thing," Dr. Perera said in a literature review discussion at the annual meeting of the American College of Emergency Physicians.
Radiologists still require emergency physicians in some places "to make patients drink those big bottles" of contrast. "It takes about 6 hours to drink that contrast and let it pass through; that bed is pretty much done for your shift," he observed.
"We would like not to have to do IV contrast [too], but we need to move with radiologists" on that decision, and the literature has not reached that conclusion, he said. Meanwhile, "if you’re thinking about mesenteric ischemia, thrombosis, abdominal aortic aneurysm" or some other vascular cause of abdominal pain, "you want to consider giving IV contrast."
Pancreatic and intestinal fluid alone adequately opacifies the lumen of the bowel, enabling visualization of bowel loops and abrupt, diagnostic changes in lumen caliber, he said.
Alternatively, IV contrast is needed to detect bowel ischemia. The wall of ischemic intestines will not take up contrast, and the twisting of mesenteric vessels will often be apparent.
Dr. Perera reported having no relevant conflicts of interest.
SEATTLE – Oral contrast is almost always unnecessary when performing a CT scan to work up adults with acute abdomens. Further, intravenous contrast is needed only when vascular causes of pain are suspected, according to Dr. Phillips Perera, a clinical associate professor of emergency medicine at Stanford (Calif.) University Medical Center.
As with everything in medicine, there are rare exceptions to this advice, he said. Oral contrast can be helpful to confirm the presence of a fistula in a postcolectomy patient, for example.
With the growth of endovascular repair of abdominal aortic aneurysms, patients with procedural complications including leaks and postop pain are increasingly presenting in emergency departments. Intravenous contrast is needed in those cases, and "more and more of these patients will be coming into the emergency department in the next few years," he said.
Forgoing oral contrast "allows us to get our patients through the emergency department much faster, and we don’t lose [diagnostic] accuracy." It also reduces radiation exposure, because noncontrast CT studies take less time, he said. The sensitivity of noncontrast CT is 93% for detecting acute appendicitis, with a specificity of 96% (Ann. Emerg. Med. 2010;55:51-59).
Recent studies indicate noncontrast CTs work well to diagnose most causes of acute abdominal pain in adults, including appendicitis, diverticulitis, kidney stones, and large ovarian cysts at risk for ovarian torsion (J. Endourol. 2008;22:2441-5).
"You only [lose] about two percentage points" on diagnostic accuracy by forgoing contrast, and the difference in one large study (World J. Surg. 2010;34:699-703) "was not statistically significant, which I think is the most important thing," Dr. Perera said in a literature review discussion at the annual meeting of the American College of Emergency Physicians.
Radiologists still require emergency physicians in some places "to make patients drink those big bottles" of contrast. "It takes about 6 hours to drink that contrast and let it pass through; that bed is pretty much done for your shift," he observed.
"We would like not to have to do IV contrast [too], but we need to move with radiologists" on that decision, and the literature has not reached that conclusion, he said. Meanwhile, "if you’re thinking about mesenteric ischemia, thrombosis, abdominal aortic aneurysm" or some other vascular cause of abdominal pain, "you want to consider giving IV contrast."
Pancreatic and intestinal fluid alone adequately opacifies the lumen of the bowel, enabling visualization of bowel loops and abrupt, diagnostic changes in lumen caliber, he said.
Alternatively, IV contrast is needed to detect bowel ischemia. The wall of ischemic intestines will not take up contrast, and the twisting of mesenteric vessels will often be apparent.
Dr. Perera reported having no relevant conflicts of interest.
EXPERT ANALYSIS FROM THE ACEP SCIENTIFIC ASSEMBLY 2013
Marked BPN elevations found in a third of diastolic HF patients
VANCOUVER, B.C. – B-type natriuretic peptide elevations above 1,000 pg/mL may herald worse prognosis in patients with diastolic heart failure but normal renal function, according to a retrospective database analysis from the University of California, Davis.
Among 421 hospitalized patients with diastolic heart failure – heart failure (HF) with ejection fractions above 45% – investigators found that 117 (28%) patients had B-type natriuretic peptide (BNP) levels above 1,000 pg/mL.
Fifty of those patients (43%) had stage IV or V chronic kidney disease, compared with 7 (13%) of the 54 diastolic HF patients with BNPs below 100 pg/mL. The team also found a significant relationship between estimated glomerular filtration rate (eGFR) and BNP (R = 0.39). In most cases, BNP levels above 1,000 pg/mL "were likely due to reduced [renal] clearance and associated factors. The degree of renal dysfunction is related to the degree of BNP elevation," said senior investigator Dr. Saul Schaefer, professor at the university and also chief of cardiology at the Veterans Affairs Medical Center in Sacramento.
But 25 patients (21%) with BNPs above 1,000 pg/mL "actually had normal renal function; that is, an [eGFR] greater than 60 mL/min per 1.73 m2. It’s unclear why these patients would have such an elevated BNP. They were older [mean age 70.2 years vs. 67.7 years] and had slightly reduced ejection fractions in comparison to the overall group," he said at the 18th World Congress on Heart Disease.
"My guess is that these patients with high BNPs and normal renal function have more severe abnormalities and diastolic failure. It’s a potential marker of higher risk. We could potentially follow these patients more closely and treat them more aggressively," he said.
Before that happens, however, "we need to prospectively look at these patients and see if they can be distinguished from the lower-BNP patients, and track them to see whether their prognosis is adversely affected," Dr. Schaefer said.
Compared with diastolic HF patients in the study with BNPs below 100 pg/mL, the 117 with levels above 1,000 pg/mL tended to be older (68 vs. 61.4 years), have higher troponin levels (0.2 vs. 0 ng/mL), and have greater use of antihypertensive medications, suggesting that they had more chronic hypertension. There were no associations between markedly elevated BNP and gender, diabetes, or ischemic heart disease. Echo parameters did not predict BNP.
Dr. Schaefer said that he had no relevant disclosures.
VANCOUVER, B.C. – B-type natriuretic peptide elevations above 1,000 pg/mL may herald worse prognosis in patients with diastolic heart failure but normal renal function, according to a retrospective database analysis from the University of California, Davis.
Among 421 hospitalized patients with diastolic heart failure – heart failure (HF) with ejection fractions above 45% – investigators found that 117 (28%) patients had B-type natriuretic peptide (BNP) levels above 1,000 pg/mL.
Fifty of those patients (43%) had stage IV or V chronic kidney disease, compared with 7 (13%) of the 54 diastolic HF patients with BNPs below 100 pg/mL. The team also found a significant relationship between estimated glomerular filtration rate (eGFR) and BNP (R = 0.39). In most cases, BNP levels above 1,000 pg/mL "were likely due to reduced [renal] clearance and associated factors. The degree of renal dysfunction is related to the degree of BNP elevation," said senior investigator Dr. Saul Schaefer, professor at the university and also chief of cardiology at the Veterans Affairs Medical Center in Sacramento.
But 25 patients (21%) with BNPs above 1,000 pg/mL "actually had normal renal function; that is, an [eGFR] greater than 60 mL/min per 1.73 m2. It’s unclear why these patients would have such an elevated BNP. They were older [mean age 70.2 years vs. 67.7 years] and had slightly reduced ejection fractions in comparison to the overall group," he said at the 18th World Congress on Heart Disease.
"My guess is that these patients with high BNPs and normal renal function have more severe abnormalities and diastolic failure. It’s a potential marker of higher risk. We could potentially follow these patients more closely and treat them more aggressively," he said.
Before that happens, however, "we need to prospectively look at these patients and see if they can be distinguished from the lower-BNP patients, and track them to see whether their prognosis is adversely affected," Dr. Schaefer said.
Compared with diastolic HF patients in the study with BNPs below 100 pg/mL, the 117 with levels above 1,000 pg/mL tended to be older (68 vs. 61.4 years), have higher troponin levels (0.2 vs. 0 ng/mL), and have greater use of antihypertensive medications, suggesting that they had more chronic hypertension. There were no associations between markedly elevated BNP and gender, diabetes, or ischemic heart disease. Echo parameters did not predict BNP.
Dr. Schaefer said that he had no relevant disclosures.
VANCOUVER, B.C. – B-type natriuretic peptide elevations above 1,000 pg/mL may herald worse prognosis in patients with diastolic heart failure but normal renal function, according to a retrospective database analysis from the University of California, Davis.
Among 421 hospitalized patients with diastolic heart failure – heart failure (HF) with ejection fractions above 45% – investigators found that 117 (28%) patients had B-type natriuretic peptide (BNP) levels above 1,000 pg/mL.
Fifty of those patients (43%) had stage IV or V chronic kidney disease, compared with 7 (13%) of the 54 diastolic HF patients with BNPs below 100 pg/mL. The team also found a significant relationship between estimated glomerular filtration rate (eGFR) and BNP (R = 0.39). In most cases, BNP levels above 1,000 pg/mL "were likely due to reduced [renal] clearance and associated factors. The degree of renal dysfunction is related to the degree of BNP elevation," said senior investigator Dr. Saul Schaefer, professor at the university and also chief of cardiology at the Veterans Affairs Medical Center in Sacramento.
But 25 patients (21%) with BNPs above 1,000 pg/mL "actually had normal renal function; that is, an [eGFR] greater than 60 mL/min per 1.73 m2. It’s unclear why these patients would have such an elevated BNP. They were older [mean age 70.2 years vs. 67.7 years] and had slightly reduced ejection fractions in comparison to the overall group," he said at the 18th World Congress on Heart Disease.
"My guess is that these patients with high BNPs and normal renal function have more severe abnormalities and diastolic failure. It’s a potential marker of higher risk. We could potentially follow these patients more closely and treat them more aggressively," he said.
Before that happens, however, "we need to prospectively look at these patients and see if they can be distinguished from the lower-BNP patients, and track them to see whether their prognosis is adversely affected," Dr. Schaefer said.
Compared with diastolic HF patients in the study with BNPs below 100 pg/mL, the 117 with levels above 1,000 pg/mL tended to be older (68 vs. 61.4 years), have higher troponin levels (0.2 vs. 0 ng/mL), and have greater use of antihypertensive medications, suggesting that they had more chronic hypertension. There were no associations between markedly elevated BNP and gender, diabetes, or ischemic heart disease. Echo parameters did not predict BNP.
Dr. Schaefer said that he had no relevant disclosures.
AT THE 18TH WORLD CONGRESS ON HEART DISEASE
Major finding: Among 421 hospitalized patients with diastolic heart failure, 117 (28%) had BNP levels above 1,000 pg/mL.
Data Source: Record review.
Disclosures: Dr. Schaefer said that he had no relevant disclosures.
Team care doesn’t reduce physician burnout
SAN DIEGO – Team-based care – a cornerstone of redesigning clinics into patient-centered medical homes – won’t necessarily decrease physician burnout, according to researchers from Allina Health, a large Midwestern integrated health system based in Minneapolis.
Among other benefits, team-based care is supposed to decrease the workload on physicians – a major driver of doctor burnout – by adding a few extra hands to help with paperwork, phone calls, and other tasks.
It didn’t seem to do that, though, in the study. Investigators administered the Maslach Burnout Inventory to doctors, mid-level providers, clinical assistants, and other staff at four community primary care clinics as they switched to a team-care approach, with three clinical assistants for every two doctors, and at 3, 6, and 12 months thereafter.
The findings were compared with results from Maslach surveys administered at the same time intervals to physicians and others at four community primary care clinics that stuck to the traditional one physician/one clinical assistant staffing model. Both rural and suburban clinics run by Allina Health participated in the study.
"Much to our chagrin, we found no significant impact of team care on burnout prevalence and severity" at any of the survey points. "There was a slight trend early [for doctors] that degraded over time, and there was a slight [favorable] trend among clinical assistants ... but nothing statistically significant," said lead investigator Dr. William Spinelli, a family practitioner in Hastings, Minn.
Response rates varied at each time interval, with 60-96 providers – physicians, physician assistants, and nurse practitioners – filling out the Maslach at each survey point, split roughly equally among team care and control clinics.
At baseline, about 35% (17) of providers at team-care clinics hit the Maslach mark for burnout as did about 40% (19) of providers at control-group clinics. That rose to about 50% (30) in both settings at 3 months, and stayed at about 50% (17) in the control clinics but dropped back to about 35% (12) in the team-care clinics at month 6. At 1 year, burnout among team-care providers remained at about 35% (11), but had fallen to 30% (10) among control-clinic providers. The differences were not statistically significant.
Overall, women providers were slightly less burned out than men, but gender offered no protective effect on further analysis (for example, odds ratio at the 12-month survey point 1.12; 95% confidence interval 0.56-2.42; P = 0.75). There did, however, seem to be a protective effect for "decreasing from full-time [36 hours of direct outpatient contact per week, for instance] to part-time work, which is interesting because there are data in the literature suggesting there is no difference," Dr. Spinelli said.
Overall, 630 providers, clinical assistants, and other staff members, a category that included, for example, licensed practical nurses and x-ray technicians, participated in the study; they completed 1,405 electronic surveys.
Across the three job categories in both settings, most of the study participants were white, female, and 31-60 years old. Full-time status at each of the study points ranged from 37.8% to 50.8%, and most participants had been on the job for more than 4 years.
Burnout prevalence was higher among doctors than among clinical assistants and other staffers. Clinical assistant burnout prevalence hovered at about 25% in both settings throughout the study, and at about 30% for other workers. Burnout was less common, but not significantly less, in both job categories in team-care clinics.
"When you begin to look at design initiatives focused on the providers, we also have to ask if those initiatives are going to benefit other workers. We have another study" in process "that suggests there is a differential set of contributing factors for burnout; for providers, it’s definitely workload, for [others] it turns out that workload is far less of an issue than [are] things such as fairness and rewards. There’s not going to be a one size fits all solution" for burnout in the clinic, Dr. Spinelli said.
National data suggests burnout approaches 46% for all U.S. physicians, and about 50% for family physicians.
The Maslach Burnout Inventory is a 22-question measure of emotional exhaustion, cynicism, depersonalization, and other issues. Burnout is defined as meeting certain cut-points on such problems. Dr. Spinelli has no disclosures.
SAN DIEGO – Team-based care – a cornerstone of redesigning clinics into patient-centered medical homes – won’t necessarily decrease physician burnout, according to researchers from Allina Health, a large Midwestern integrated health system based in Minneapolis.
Among other benefits, team-based care is supposed to decrease the workload on physicians – a major driver of doctor burnout – by adding a few extra hands to help with paperwork, phone calls, and other tasks.
It didn’t seem to do that, though, in the study. Investigators administered the Maslach Burnout Inventory to doctors, mid-level providers, clinical assistants, and other staff at four community primary care clinics as they switched to a team-care approach, with three clinical assistants for every two doctors, and at 3, 6, and 12 months thereafter.
The findings were compared with results from Maslach surveys administered at the same time intervals to physicians and others at four community primary care clinics that stuck to the traditional one physician/one clinical assistant staffing model. Both rural and suburban clinics run by Allina Health participated in the study.
"Much to our chagrin, we found no significant impact of team care on burnout prevalence and severity" at any of the survey points. "There was a slight trend early [for doctors] that degraded over time, and there was a slight [favorable] trend among clinical assistants ... but nothing statistically significant," said lead investigator Dr. William Spinelli, a family practitioner in Hastings, Minn.
Response rates varied at each time interval, with 60-96 providers – physicians, physician assistants, and nurse practitioners – filling out the Maslach at each survey point, split roughly equally among team care and control clinics.
At baseline, about 35% (17) of providers at team-care clinics hit the Maslach mark for burnout as did about 40% (19) of providers at control-group clinics. That rose to about 50% (30) in both settings at 3 months, and stayed at about 50% (17) in the control clinics but dropped back to about 35% (12) in the team-care clinics at month 6. At 1 year, burnout among team-care providers remained at about 35% (11), but had fallen to 30% (10) among control-clinic providers. The differences were not statistically significant.
Overall, women providers were slightly less burned out than men, but gender offered no protective effect on further analysis (for example, odds ratio at the 12-month survey point 1.12; 95% confidence interval 0.56-2.42; P = 0.75). There did, however, seem to be a protective effect for "decreasing from full-time [36 hours of direct outpatient contact per week, for instance] to part-time work, which is interesting because there are data in the literature suggesting there is no difference," Dr. Spinelli said.
Overall, 630 providers, clinical assistants, and other staff members, a category that included, for example, licensed practical nurses and x-ray technicians, participated in the study; they completed 1,405 electronic surveys.
Across the three job categories in both settings, most of the study participants were white, female, and 31-60 years old. Full-time status at each of the study points ranged from 37.8% to 50.8%, and most participants had been on the job for more than 4 years.
Burnout prevalence was higher among doctors than among clinical assistants and other staffers. Clinical assistant burnout prevalence hovered at about 25% in both settings throughout the study, and at about 30% for other workers. Burnout was less common, but not significantly less, in both job categories in team-care clinics.
"When you begin to look at design initiatives focused on the providers, we also have to ask if those initiatives are going to benefit other workers. We have another study" in process "that suggests there is a differential set of contributing factors for burnout; for providers, it’s definitely workload, for [others] it turns out that workload is far less of an issue than [are] things such as fairness and rewards. There’s not going to be a one size fits all solution" for burnout in the clinic, Dr. Spinelli said.
National data suggests burnout approaches 46% for all U.S. physicians, and about 50% for family physicians.
The Maslach Burnout Inventory is a 22-question measure of emotional exhaustion, cynicism, depersonalization, and other issues. Burnout is defined as meeting certain cut-points on such problems. Dr. Spinelli has no disclosures.
SAN DIEGO – Team-based care – a cornerstone of redesigning clinics into patient-centered medical homes – won’t necessarily decrease physician burnout, according to researchers from Allina Health, a large Midwestern integrated health system based in Minneapolis.
Among other benefits, team-based care is supposed to decrease the workload on physicians – a major driver of doctor burnout – by adding a few extra hands to help with paperwork, phone calls, and other tasks.
It didn’t seem to do that, though, in the study. Investigators administered the Maslach Burnout Inventory to doctors, mid-level providers, clinical assistants, and other staff at four community primary care clinics as they switched to a team-care approach, with three clinical assistants for every two doctors, and at 3, 6, and 12 months thereafter.
The findings were compared with results from Maslach surveys administered at the same time intervals to physicians and others at four community primary care clinics that stuck to the traditional one physician/one clinical assistant staffing model. Both rural and suburban clinics run by Allina Health participated in the study.
"Much to our chagrin, we found no significant impact of team care on burnout prevalence and severity" at any of the survey points. "There was a slight trend early [for doctors] that degraded over time, and there was a slight [favorable] trend among clinical assistants ... but nothing statistically significant," said lead investigator Dr. William Spinelli, a family practitioner in Hastings, Minn.
Response rates varied at each time interval, with 60-96 providers – physicians, physician assistants, and nurse practitioners – filling out the Maslach at each survey point, split roughly equally among team care and control clinics.
At baseline, about 35% (17) of providers at team-care clinics hit the Maslach mark for burnout as did about 40% (19) of providers at control-group clinics. That rose to about 50% (30) in both settings at 3 months, and stayed at about 50% (17) in the control clinics but dropped back to about 35% (12) in the team-care clinics at month 6. At 1 year, burnout among team-care providers remained at about 35% (11), but had fallen to 30% (10) among control-clinic providers. The differences were not statistically significant.
Overall, women providers were slightly less burned out than men, but gender offered no protective effect on further analysis (for example, odds ratio at the 12-month survey point 1.12; 95% confidence interval 0.56-2.42; P = 0.75). There did, however, seem to be a protective effect for "decreasing from full-time [36 hours of direct outpatient contact per week, for instance] to part-time work, which is interesting because there are data in the literature suggesting there is no difference," Dr. Spinelli said.
Overall, 630 providers, clinical assistants, and other staff members, a category that included, for example, licensed practical nurses and x-ray technicians, participated in the study; they completed 1,405 electronic surveys.
Across the three job categories in both settings, most of the study participants were white, female, and 31-60 years old. Full-time status at each of the study points ranged from 37.8% to 50.8%, and most participants had been on the job for more than 4 years.
Burnout prevalence was higher among doctors than among clinical assistants and other staffers. Clinical assistant burnout prevalence hovered at about 25% in both settings throughout the study, and at about 30% for other workers. Burnout was less common, but not significantly less, in both job categories in team-care clinics.
"When you begin to look at design initiatives focused on the providers, we also have to ask if those initiatives are going to benefit other workers. We have another study" in process "that suggests there is a differential set of contributing factors for burnout; for providers, it’s definitely workload, for [others] it turns out that workload is far less of an issue than [are] things such as fairness and rewards. There’s not going to be a one size fits all solution" for burnout in the clinic, Dr. Spinelli said.
National data suggests burnout approaches 46% for all U.S. physicians, and about 50% for family physicians.
The Maslach Burnout Inventory is a 22-question measure of emotional exhaustion, cynicism, depersonalization, and other issues. Burnout is defined as meeting certain cut-points on such problems. Dr. Spinelli has no disclosures.
AT THE AAFP 2013 SCIENTIFIC ASSEMBLY
Major finding: Surveyed a year after implementing a team-care staffing model, 35% (11) of providers met Maslach criteria for burnout; 30% (10) of providers were burned out at clinics that had stuck with a traditional staffing model. The difference was not statistically significant.
Data Source: Prospective, controlled, cross-sectional pilot study.
Disclosures: The investigators have no disclosures.